Chua H C, Tow A, Tan E S
Department of Neurology, Tan Tock Seng Hospital Brain and Spine Centre, Singapore.
Ann Acad Med Singap. 1996 Jul;25(4):553-7.
This study describes the various types of neurogenic bladder in spinal cord injury in relation to the level of lesion, defines the aims of bladder management, and discusses the importance of highly individualised management strategies and long-term follow-up. Urodynamic studies were done on 47 new patients with traumatic spinal cord injury when they had return of reflexic bladder activity. This study was conducted over a one-year period. Fifty-five per cent (n = 26) sustained cervical injuries (38.5% complete, 61.5% incomplete), 12.8% (n = 6) had thoracic injuries, 29.8% (n = 14) had lumbar injuries, and 2.1% (n = 1) had sacral injury. The urodynamic patterns according to injury level are shown in Table I. In patients with complete cervical injuries, 80% had detrusor sphincter dyssynergia (DSD), and areflexia was seen in 20% (n = 2). Of those with incomplete cervical injury, 7 (43.8%) had DSD, 5 (31.3%) had detrusor hyperrflexia without DSD, and 2 (12.5%) had areflexia or hyporeflexia. Normal urodynamic studies were only found in patients with incomplete cervical injury (n = 2). Of the 6 patients with thoracic injury, 4 (66.6%) had detrusor areflexia and 2 had DSD. The 2 patients with DSD had injury levels at T4/T6 and T5 respectively. Eleven (78.6%) patients with lumbar injury had detrusor areflexia, one (7.1%) had detrusor hyperreflexia (without DSD), and 2 (14.3%) had a normal urodynamic study. The various patterns of bladder management are shown in Table II. In total, there were 17 patients with DSD. Of these, 9 (52.9%) elected for intermittent catheterisation together with pharmacological therapy, 5 (29.4%) passed urine via spontaneous voiding/tapping, one (5.9%) had an in-dwelling catheter by virtue of his lack of manual dexterity and no care-giver, and 2 (11.8%) patients opted for sacral anterior root stimulator (SARS) or the Brindley device. Of the 6 patients with detrusor hyperreflexia, 4 (66.7%) passed urine spontaneously and 2 (33.3%) patients choose intermittent catheterisation together with pharmacologic therapy. There were 20 patients with detrusor areflexia/hyporeflexia; 15 (75%) were on clean intermittent catheterisation, 4 (20%) voided via straining and 1 (5%) had a suprapubic catheter inserted. The re-discovery of intermittent self-catheterisation, improved medical care, bladder training and surgical advances have enabled the goals of bladder management to be realised; namely safe bladder pressures, low residual urine volume and the attainment of continence.
本研究描述了脊髓损伤中与损伤水平相关的各种类型神经源性膀胱，明确了膀胱管理的目标，并讨论了高度个体化管理策略和长期随访的重要性。对47例创伤性脊髓损伤新患者在其反射性膀胱活动恢复时进行了尿动力学研究。本研究为期一年。55%（n = 26）为颈椎损伤（38.5%完全性损伤，61.5%不完全性损伤），12.8%（n = 6）为胸椎损伤，29.8%（n = 14）为腰椎损伤，2.1%（n = 1）为骶骨损伤。根据损伤水平的尿动力学模式见表I。在完全性颈椎损伤患者中，80%有逼尿肌括约肌协同失调（DSD），20%（n = 2）表现为无反射。在不完全性颈椎损伤患者中，7例（43.8%）有DSD，5例（31.3%）有无DSD的逼尿肌反射亢进，2例（12.5%）有无反射或反射减退。仅在不完全性颈椎损伤患者中发现尿动力学检查正常（n = 2）。在6例胸椎损伤患者中，4例（66.6%）有逼尿肌无反射，2例有DSD。2例有DSD的患者损伤水平分别在T4/T6和T5。11例（78.6%）腰椎损伤患者有逼尿肌无反射，1例（7.1%）有逼尿肌反射亢进（无DSD），2例（14.3%）尿动力学检查正常。膀胱管理的各种模式见表II。总共有17例DSD患者。其中，9例（52.9%）选择间歇性导尿并辅以药物治疗，5例（29.4%）通过自主排尿/轻拍排尿，1例（5.9%）因缺乏手部灵活性且无照料者而留置导尿管，2例（11.8%）患者选择骶前根刺激器（SARS）或布林德利装置。在6例逼尿肌反射亢进患者中，4例（66.7%）自主排尿，2例（33.3%）患者选择间歇性导尿并辅以药物治疗。有20例逼尿肌无反射/反射减退患者；15例（75%）采用清洁间歇性导尿，4例（20%）通过用力排尿，1例（5%）插入耻骨上导尿管。间歇性自我导尿的重新发现、医疗护理的改善、膀胱训练和手术进展使膀胱管理的目标得以实现；即安全的膀胱压力、低残余尿量和实现控尿。
